Date:
Last Name:
First Name:
Gender: MaleFemaleOther
Previous Last Name:
Date of Birth:
Age:
Height:
Weight:
Street Address:
City:
State:
Zip:
Primary Phone:
Email Address:
Contact Preferences: PhoneEmail
May we call and leave messages? YesNo
Primary Language:
Primary Care Provider:
Provider Phone:
Name:
Phone:
Allergies:
Medications & Supplements:
Surgical History:
Females: Are you pregnant or breastfeeding? YesNo
Electrolyte Imbalance / Abnormal Labs: HypermagnesemiaHypercalcemiaHypokalemiaHemochromatosisOther
NoneFever/chillsRashChest painDifficulty urinating
Fatigue or low energyStressPoor diet due to busy lifestyleBrain fog or trouble concentratingLow mood or depressionHeadaches or migrainesWeight gain or difficulty losing weightSlow metabolismAsthma and AllergiesRecent surgical procedureRecent illnessCold or flu symptomsFacial wrinkles or fine linesDull or dry skinMalabsorption issuesOther
AcneArthritisAsthmaHigh Blood PressureLow Blood PressureCancerChronic Fatigue SyndromeCoronary artery diseaseCongestive heart failureCrohn's diseaseDepressionDiabetesEczemaEpstein-Barr VirusG6PD DeficiencyHigh CholesterolHigh TriglyceridesHepatitisHIVHivesHyperthyroidInflammatory bowelKidney ProblemsKidney StonesLiver diseaseLupus SLEMigrainesMultiple SclerosisOverweightParathyroid problems-highPsoriasisRefluxRheumatoid arthritisSarcoidosisSeizuresSickle Cell AnemiaStrokeUlcerative colitisUnderweightVitiligoFibromyalgiaOther
Caffeine use:
Alcohol use (# of heavy drinking days past year):
Tobacco usage: NeverFormerCurrent
If smoker, packs per day:
Total years smoking:
Tobacco type:
Recreational drug use? YesNo
If yes, which & how often:
Occupation:
I, , being the parent/guardian of , a minor child, authorize The Scarlet Drip to perform IV/IM nutrient therapy on .
I have been given the opportunity to ask questions about the benefits and risks of IV/IM nutrient therapies, alternative therapies, risks of non-treatment, procedures to be used, and the risks and hazards involved. I believe I have sufficient information to give this informed consent for treatment of my minor child, for whom I am authorized to make this request for treatment. I release The Scarlet Drip and all the medical staff from all liabilities for any complications or damages associated with such IV/IM nutrient therapy.
I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.
Guardian Signature: (type full name)
